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Sunday, October 02, 2011

where context is key

The season that it is cool enough to wear sweaters and scarves, but not cold enough to have to wear those big poofy winter jackets. Since we live in Atlanta, weather like this will last until, oh, just around Thanksgiving, and resume probably by the end of January. Not a bad deal.

(Also, if you're thinking that the only reason to have kids is to dress them up in cute little clothes for the fall, you're 75% right. The other 25% is to legitimize buying a lot of Halloween candy. DO IT FOR THE CHILDREN.)

Anyway, this spawned a good amount of discussion on Twitter when I first posted it, but I just wanted to open it up here in the > 140 character arena. An article in The New York Times today detailed the growing trend of non-physician practitioners (such as, to give one example, nurse practitioners) introducing themselves as "doctors" to patients in a clinical setting. One argument is that, as someone with a doctoral degree, they deserve the honorific, and earning these doctoral degrees (I'll quote directly from the article here) "can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients."

My personal take is this: indeed, anyone who earns a doctoral degree has earned the right to be called "doctor." No one is disputing that, or taking respect or recognition from anyone who has earned that doctorate. But I would also point out that the term "doctor" has a very specific meaning in a clinical setting, and that the shades of grey ("I'm not a medical doctor but I do have a doctorate in nursing,") can be confusing or simply lost on a patient or their family, especially in the setting of an already complicated interaction in the hospital.

Some people argue that there is ego involved, and I don't doubt it--and might I point out there's likely a lot of ego on both sides, from the physician side for wanting to "defend" the title of doctor, and from the non-physician side in their desire to assert their own rich and well-deserved credentials. But like with most things in medicine, context is everything, and if we can all agree that the shades of differentiation of the term "doctor" are particularly fraught in the clinical milieu (and thus confusing to patients) perhaps ego can and should be put aside in the name of transparency.

There is also the issue of responsibility. In most situations in the hospital, the physician has the ultimate responsibility for the patient and what happens to them. As the physician, I am the bottom line, and whatever happens "under" me (someone misinterprets my order, a medical trainee under my supervision causes patient injury, a medication error occurs not directly because of me but under my watch)--in the end that's my responsibility and no one else's. When I introduce myself as "Doctor Au," that's part of the implicit understanding, and patients need to enter into that doctor-patient relationship where trust and the assumption of that ultimate responsibility go hand in hand. It may not seem like more than semantics to some people, but when you present yourself to a patient as their "doctor," in a hospital, that has to mean something very specific, for the understanding and ultimately the protection of the patients under all of our care.

In my mind, if someone calls themselves "doctor" during a professional interaction in the hospital, I assume that they are a physician, and I think I'm safe to say that most patients feel the same way. Just the same way that, if I'm in a college French class and the professor introduces him or herself "Doctor Webb," I assume that they have an academic doctoral degree and don't start, you know, taking off my clothes and showing them my rashes. In medicine, context is everything.

(Incidentally, on the flip side, if a patient asks me to call them "Doctor So-and-so," I will absolutely oblige them, no questions asked. But then again, I will pretty much call a patient whatever they ask me to call them, including the one patient I had who specifically requested that, when we woke up him up from anesthesia after surgery, we address him as "Big Poppa" because it was the only name he really responded to. No problem, uh, Mr. Poppa.)

72 comments:

I have the exactly the same views. There are many hospitals that are putting in place guidelines in the bylaws on who can and cannot use the term Dr in the clinical setting. Some hospitals are even color coding the scrubs each professional wears so people will know. I don't remember which hospital it was, but at UMaryland or JHU the anesthesiologist wear pink scrubs.

I am a med student. At my current rotation sites, the scrubs are color coded by job (RT, housekeeping, nurse's assistant, etc) . However, I see plenty of non-doctors wearing the same color scrubs as the medical staff.

I am a 4th year medical student. I always introduce myself as medical student over "student doctor" 1) because i think the latter sounds quite douchey and 2) because patients will simply grab onto "doctor" and run with it. I think people other than actual, licensed physicians who want refer to themselves as "doctor" in the patient-care setting are doing nothing but misleading the patient and associated family. Furthermore, as you said they still do not assume any of the malpractice and other responsibilities of a physician...A fairly important point I think.

I completely agree with you. I am yet another anonymous (first year) med student. :) I had a PhD before I started med school (in something unrelated to medicine), and I absolutely do not want people calling me "doctor" in a medical setting until I am one. I am not a doctor yet and I really don't want people thinking that I am!

I completely agree with what you wrote, and left a comment on that awful "Well" blog on the NYT (don't get me started on how much I can't stand TPP). Here it is below:

I don't think physician-doctors have any problem with people who have doctorates being referred to as "Dr". I think the problem arises when there is someone in the clinical field who introduces themselves as "Dr" but is a physical therapist/nurse practitioner/physician assistant because it is misleading to the patient. The patient thinks they are seeing an MD-Dr, and regardless of whether that is presumptuous on his/her part, it is the truth.

Also, what is so derogatory/bad about referring to oneself as "Nurse" or "Nurse Practioner"? If they truly believe they can provide equal care to an MD, which they absolutely can do, then they should lobby to increase awareness of the title "NP" in the general population. The aim should be to have acceptance of the title "NP" as a legitimate health care provider, not to drop it and try to fool the pubic into believing you are the "same as an MD".

I feel that if the NPs want to call themselves "Dr", then they should be required to do residency-type training and carry their own malpractice insurance so that when the patient gets sick they can't just hide behind the MD that is responsible for them-- let them bear ultimate responsibility for a patient's care. I don't think they should be able to have it both ways-- i.e., one can't get the prestige and respect of being called "Dr" but none of the responsibility, which is what they seem to want.

At Maryland everyone who works at Shock Trauma (no matter their role) wears pink scrubs. Not sure if anesthesia is assigned pink at JHU, but it definitely isn't an assigned color for anesthesiologists as UMD.

I agree with Anon @ 6:19. The average person who doesn't work in healthcare and has had limited exposure to the hospital hierarchy will absolutely think that an NP who introduces him/herself as a "doctor" is someone who has an MD/DO.

If it's a matter of pride to the NPs, then there needs to be more patient education and campaigning to make the "NP" title accepted and respected as health providers.

I agree! As a PGY-1, I always introduce myself as "Dr V, a junior resident with X team." I figure that by saying "doctor," "junior" and then mentioning the team, I'm giving the patient as much information as I can in one sentence. I think color-coding might be going a bit far, but I DO wish that teaching hospitals would have big informative signs in the waiting rooms about all the different people involved in patient care - teaching hospitals are so confusing, and I think this would help!

As someone outside of the medical field and without a ph.d, I don't find it confusing to address non-physician MDs as doctors. I usually read name tags to see what degrees they have. I have friends who are MDs, DOs, and Au.Ds. My friend who has her Au.D. (doctor of audiology) has every right to be addressed in the with Dr. in the clinical setting. She has earned the degree and a professional in her field. The ENTs in her office respect her expertise and training to address her as Dr. in front of the patients.

Anyway, I agree with you. I'll probably get a PhD someday, but it will likely be in physiology, just for fun. I will have earned the title, yes, but I absolutely think patients take the title and run with it, missing the distinction between clinical practice. I won't be a physician, because I decided not to go to medical school. Period.

I'd like to throw out, though, that RNs get the same ire when nurse aides are addressed as "The Nurse". If I had a dollar for every family practice doc who referred to their MA as "my nurse"...

I completely agree with this post. If nurses want to call themselves doctors within the medical community, then they should be required to earn the same level of training and expertise that we, physicians, are required to go through. Most patients do not know the difference, and may simply be more confused, rather than enlightened, by the terminology.

There was a great article not too long ago on Student Doctor Network, comparing the levels of training between an MD and a DNP:http://www.studentdoctor.net/2011/04/sdn-reports-the-dnp-degree/The level of training of an MD vs a DNP is very very different.

I am outside the field and have a Ph.D. so I fully understand the amount of work and sacrifice earning the degree entails. That said, in a clinical setting where my care is at stake, you damn well better have an M.D. if you're going to refer to yourself as "doctor" when speaking with me if I'm talking to you about my care. It's not that I think that medical doctors are superior beings worthy of more respect than anyone else, because I don't. Rather, receiving medical care can be stressful and serious and I do not have the time or the patience to have to worry about assuming that someone I'm speaking with about medical/surgical issues has the expertise of a medical degree when they do not.

First and foremost, I should be completely transparent and tell you that I am less than a year away from graduating as an NP.

The first thing that I want to clear up is the misconception that NPs do NOT have malpractice insurance and cannot be held accountable for making errors. This is not true, at least here in Massachusetts and in other states in New England. Perhaps there are other areas of the country where NPs can "hide" behind doctors, but that isn't the case here. I think we are somewhat less apt to be sued solely because we don't typically practice in the high-malpractice areas of anesthesia, surgery, and OB, but we do (unless we are very very stupid) care malpractice insurance and we can certainly be taken to court for negligence or malpractice (as was emphasized into us just last week in class).

Second, I completely agree that NPs need a residency program. While medical students have the luxury of having an official residency program to further their training after graduating with an MD, NPs are typically hired at their first job with the qualifier that they are brand-new practitioners and will need to be precepted (with no monetary compensation to the preceptor) for at least a year after hire. It is somewhat unspoken, and I for one would LOVE to have an official residency program.

Third, I have been thinking recently about the differences between medical training and nurse practitioner training. I am quite aware that the level of information taught to us is much different (and lower) than that taught to students in medical school, but at the same time, part of the reason that our clinical hours are so much lower is that we do not have exposure to all of the specialties that are out of our scope of practice, including surgery, anesthesiology, radiology, and neurology.

Fourth, I think that until a lot more education is done regarding what NPs can and cannot do (as evidenced by some of the comments here), confusion will continue to exist. The number of patients I have seen who have referred to me as Dr. (or my preceptor as Dr.) despite me introducing myself as a nurse practitioner student is large. People do not know what NPs are, nor what they do, which is somewhat unfortunate as the number of family practice doctors dwindles and the number of nurse practitioners swells. It will be interesting to see if this changes in the next decade or so, as patients seeing FNPs as their primary care provider will most likely increase during that time period.

I think that the biggest reason my radar goes up when conversations on this topic start is that, no matter where I read about it, it always feels like physicians think we (nurse practitioners) are idiots. Take this line, for instance: "Their training is so extensive, physicians argue, that they alone should diagnose illnesses." I understand that it feels like we are encroaching on "their" territory, but until the cost of med school goes down and the number of graduates who want to go into primary care goes up, I think that physicians are going to need to understand that NPs and other "physician extenders" will be helping to fill a deficit in the primary care arena that would otherwise leave patients hanging out to dry.

I think sounds odd for a nurse to introduce themselves as doctor in the clinical setting. I hold a DNP and would not dream of calling myself dr in front of the patient. Then again, I am military and non-physicians use rank, name and then explain what part of the health team we represent.

I have seen too many residents enter rooms and never explain their roles as residents. patients deserve to know the level of practice of all providers involved.

I think a lot of this is semantics within the medical comumity. I mean most people in the hospital/clinic aren't aware that a short white coat = med student or what the color code for scrubs are. My husband sees patients for clinical trials and when he enters a room (dressed in a shirt/tie) he introduces himself by his first name, but many patients assume he's a Dr (though this assumption isn't as frequent for his female colleges...). Most people don't understand the hierarchy of a teaching hosptial, so it really comes more down to educating the general public so that they can have a better grasp of their care. (and for the record I have a PhD and have yet to introduce myself as Dr. in any setting :))

I have a Ph.D. and don't consider myself a doctor (though I have had as much training as an MD between my Ph.D. and my post-doc). But, where do you draw the line -- what about a D.O.? Do they get the right to introduce themselves as a doctor? Probably the easiest way is for MDs to introduce themselves as physicians -- no ambiguity there.

im a 4th year medical student and during my GI rotation I would always introduce myself as "medical student so and so" but the fellows and residents would always introduce me as "dr. so and so" when we saw the patients together.

I think that most patients have no idea who is walking into their room...attending, resident, intern, nurse, nursing assistant, respiratory therapist, physical therapist, dietitian, etc. etc. The NPs with DNP degrees that I've met have introduced themselves as "Dr. Smith, the nurse practitioner," but what the patient interprets her as could be something totally different. Without fail, patients consider our male nurses to be doctors, female residents to be nurses, and anyone who is African American to be a nurse's aide.

This is a tricky one. I agree with you---yes, if you have a doctorate you have a right to identify yourself as "doctor", but not sure if this is appropriate in the clinical setting where the word "doctor" is synonymous with "physician". I can see patients being misled. If this is going to become a more widespread situation (which sounds like it is) then a standardized approach to how providers identify themselves and public education is definitely necessary.

Re: Leslie's comment, above. I still think Michelle's point holds true. Yes, NPs may have their own malpractice insurance but in my practice setting, at least, there is a PHYSICIAN name on every chart as the "authorizing provider" and the NP writes "patient seen with Dr X". I have to cosign each chart in our EMR. The NPs may see the patient completely on their own & do their own billing, or they can have me come into the room also (which they tend to do with more difficult cases, & difficult families---they use their judgement). Regardless, at the end of the day, all these patients are my responsibility. If any case ultimately went to malpractice, I am 100% certain that I would be involved. Not that this answers in anyway the question of self-identification, but just wanted to support Michelle's sentiment.

Non medical person here, but ridiculously educated. When I am in a clinical setting I dont want to have to ask whether the "Dr" is an MD, OD or PhD. Clinical setting Dr should be MD or OD. Dr. Whosiwhat's is a nurse...great! but I dont want think to ask. If it is about ago, lose it. If I walked into a client meeting and introduced my self as Dr. Christine, they would laugh at me. Yeah, I have a doctoral degree, big deal.

100% agree. I'm always sure to introduce myself the first time as a "Physician Assistant," not even a "PA." How the hell is a patient suppose to know what a "PA" is? And if a patient mistakingly refers to me as "doctor" I will correct them once. I assume anything after that is purely them looking for some name to use, kind of like calling any nurse by "nurse" and not their name.

I'm all about being proud of my profession and the profession getting credit where credit is due. I don't want people thinking I'm a physician when I'm not. That takes away credit from the PA profession. I think some of the DNPs need to take a little more pride in their profession and lose the chip on their shoulder.

I think it's oversimplistic to say that "ego" explains all of the rancor that surrounds this issue, though some notion of self-aggrandizement probably makes up 80% of the comments in response to this article on the NYT webpage itself. (Warning: reading the comments as a physician may cause severe depression. Surprise, everybody hates us! As you were.)

Like I said above, there is likely some ego involved on both sides of the table, but it's a gross generalization to frame the issue as one in which all physicians are God-complex-fraught dismissive assholes, while no non-physician who insists on being called "Doctor" in a clinical setting is doing it for anything but righteous reasons completely devoid of self-interest.

If we're arguing (and not that we're arguing here, but like I said I've read far too many of the NYT comments than is probably good for me) that on one side, the term "doctor" when used to refer to non-physicians in the clinical setting is admittedly confusing for patients; yet on the other side insist that non-physician doctorates deserve to be called "doctors" by patients in the hospital, confusion be damned because the patients can read nametags and sort it all out later--who, exactly, is burnishing their ego and reputation in this scenario?

Anyway, that aside, my point is that if this is an issue of ego, it shouldn't be. It should be an issue of patient care and transparency, about clarification of roles and responsibility. And though by its very nature, ego always seems to rise to the top, it should be because of patient care that we're all getting so worked up about this in the first place, right?

Great post, I totally agree, but the issue that really gets my panties in a bunch is the whole issue of the DNP.

As a nurse, I think that the DNP is the most ridiculous, waste of time. What more can a DNP do than the NP with a Masters Degree? No hospital will want the DNP referred to as Dr., because like you said, in them medical setting they still aren't the "doctor". I know in MI, the NPs with Masters will be grandfathered in and exempt from needing the Doctorate degree to practice. That is all fine and dandy, but the Masters & Doctorate NP are still practicing at the same level - what's the purpose of going back to school to get a Doctorate when you are valued in the health system hierarchy as essentially a physician extender - NOT THE DOCTOR. I don't know if it's an attempted ego boost to nurses, but I personally think once nurses get their PhD, they are useless to the clinical world as they are too far out of touch - Keep the Masters programs for NPS, and avoid the Dr. title struggle that is bound to occur in all hospitals.

Up here in MI, I have to say I rarely here the PAs or NPs referring to themselves as Dr. in the inpatient setting. Most NPs up here will quickly correct a patient for calling them Dr. I'm sure there are a few out there that do introduce themselves as doctor, and I think it's wrong. Great Post!

It's just false advertising, really. In the clinical setting, a patient will assume someone who introduces themselves as Dr went to medical school and residency. Speaking medical-legally, patients don't like to feel lied to. If the NP makes a mistake, then the patient finds out his/her provider in charge was not actually a physician, I wonder what that does to the malpractice lawsuit... It's about being honest with patients, even if one didn't intentionally deceit.

The thing about the DNP is that starting in 2015, all new NPs will be required to have their DNP. I see no problem with a DNP introducing themselves as "Dr. So and So, the nurse practitioner," as long as they make it clear that they are not the physician. In addition, nurses themselves (not just NPs/CNSs) can be included in malpractice lawsuits--trust me, that has been made very clear in my nursing program--it's why we have liability insurance. And, honestly, I know NPs who I would rather have treat me than some physicians, and I don't just say this because I plan on becoming one after I finish my BSN and work for a few years.

I think one of the major issues here, and one that NPs should be in an uproar about, is what is clearly a money-grubbing move by nursing schools and the AAN. Now NPs will be required to have another 1 to 2 years of school for what amounts to no benefit whatsoever. The nursing doctorate is not clinical- it is in statistics and epidemiology. It will not be tied to higher pay or better patient care outcomes. Its only action will be to make the current NP degree obsolete.

What's the point? All it does is bring in $$ for nursing schools, an issue well illustrated by the fact that you can basically "buy" a DNP from an online school.

Michelle, ditto everything you have said.What I find frustrating is how much this concept disrespects the title of Nurse or Nurse Practitioner. I love nurses! I love nurse practitioners! Why is it bad to be called that?Also, where was the patient's perspective in the article? What patient wants to be sick and have to deal with his semantic nonsense? Shouldn't this be fundamentally about patient information and autonomy? Patients have the right to not be misled.I agree with the commented above - I can't stand TPP. The entire NYT health section is crap, and doesn't deserve to be part of such an excellent paper.

My guess is that nurse bella doesn't understand higher education in nursing. And probably doesn't even agree with a BSN as requirement for RN license....

And these comments are depressing.

Until physicans start respecting nurses as equals and not inferiors, this whole ridiculous discussion will continue. It is a lot about egos on both parts, but a lot of that stems from physicians whole-heartedly believing that anyone who is "smart enough" to go to medical school would have. Nurses therefore chose nursing because they clearly weren't smart enough to be a physician. And until that mindset changes, little else will.

NPs need to define their scope of practice, and have means of proving competence in it. There are many other doctoral fields in health care (PharmD, AuD, etc.) which have a separate and complementary role in the health care team compared to physicians. Nurses are not physicians; their training and knowledge base are very different, and therefore they can't expect the same rights and responsibilities as physicians. Shouldn't that be obvious?

I am a nurse, and I think NPs add value to the health care team, but there is no way I'd agree to an NP independently managing my inpatient care or placing my chest tube. Follow up clinic appointment? Maintaining protocol adherence? Sure!

Another key here is that providers in healthcare don't exist on a linear totem pole, but in a network. Different people have different strengths and are trained to do different things, with some areas of overlap.

It's in this way that it's key to point out that, in a hospital, the term "doctor" is used not as an honorific, but as a job description. Perhaps some people find that archaic, but disregarding current convention seems like willful obfuscation or just an exercise in semantics.

I am confused by anonymous at 3:09 who claims that NPs should have a scope of practice. We DO have a scope of practice, either clearly defined at the state level or in an agreement at one's place of work, depending on the state. Could you clarify what you meant by your comment?

As a resident I introduce myself as Dr. X, your medical resident... and I don't see what is wrong with introducing yourself as what you are... I happily see an NP for my routine low risk annual exam/pap smear but take my daughter to an MD for her eye surgery... different practice with different focus. One of our NPs does a great job with our teen OB clinic and all its crazy social and social work issues and an even better job sending all of her diabetics/hypertensives/etc to our high risk clinic to get additional involvement!

I talked about this with my dad, who is an attorney. He laughed when I asked if he thought his clients should be calling him Doctor. He said he didn't want the responsibility that came along with the title ... irregardless of the diploma hanging on the wall that confirms he is in fact a juris doctor. :)

Hi Leslie-I should have been more specific. In my state, NPs can do almost anything under their supervising physician's license if he or she agrees to it. I don't think that should be how a profession with a terminal degree defines how they practice. NPs should practice independently, but they need to describe explicitly what they ARE and ARE NOT trained to do in nursing school (and, IMO, one lecture on chest tube insertion does not cut it). Likewise, their training should mostly be from other nurses, not physicians.

Do you have a link to a defined nursing scope of practice? I'd love to see it. All I can find on the internet is very vague language and a reference to which states require physician supervision or not.

Reading your post I agreed with your position. However, with a bit more thought I am starting to lean the other way.

An NP, CRNA, PT, etc.. should be using the professional designation that they have earned, if that be at the doctorate level then it is what has been earned. perhaps, additional explanation should be made to describe the role of the individual when interacting with patients.

It cannot be justified for a physician or facility to mandate that a provider not use the distinction that has been earned. Individuals spend lots of time and money advancing their own education and should not be made to sit at the back of the bus because a few physicians feel it encroches on their perceived authority.

Bottom line is that healthcare is a TEAM approach and to belittle certain members of that team is not advancing anyone's cause.

Why are RT's, pharmacists, food service workers, and seemingly EVERYONE else who isn't a medical doctor allowed to wear long white coats? This has also confused me on a million different occasions, so I wonder how the patients feel.

I guess I don't understand how it is perceived as "belittling" someone to refer to them as an NP or a PharmD or what have you, if that's indeed the designation they have earned. Why is being referred to as "Doctor" an honor, but being referred to as a "Nurse Practitioner" insulting? I have worked with and learned from many excellent nurse practitioners, as well as from many brilliant pharmacists, respiratory therapists, and physician assistants, and their positions or how they chose to refer to themselves had nothing to do with how much I respected their work, nor did it in any way detract from the good they did for patients.

Transparency in team role and structure does not belittle any member of the team, nor is that my inent. And if a nurse practitioner (or other non-physician provider) feels that it lowers their worth to be referred to as such, perhaps this is more an internalized stigma than an external one.

I am writing this while currently hospitalized. (I am also a PhD and third year med student). I actually appreciate the designation of position (I am a surgical fellow, physical therapist, anesthesiologist) more than I care about title. Each day I am being seen by no less than 5 MD/DOs. Each of my providers has a different level of skills even within the "MD/DO" world. I am at a teaching hospital and I want to know if I am seeing an intern, resident or fellow. All of those are doctors, but have no where near the level of education and experience that *my* doc has.

I am seeing multiple types of doctors. Knowing exactly who they are is rather important so I ask the right question to the right person. Discussing my Orthopaedic Surgical complications with my GI Doc isn't likely to net me the information I want/need. Discussing my surgical complications with the PhD RN who is caring for me tonight (and who has worked with Med/Surg patients for 30 years), is much more likely.

I don't think it's belittling to call someone a NP, that's not the argument. I think you'd be hard pressed to find an NP who isn't proud of that title. Nursing is not the same as being a physician-- it's not meant to be. The theory is all very different.

Personally, I'm indifferent to being called a "doctor" just because I would have a doctoral degree, but that's not the point. It's a matter of respect and acknowledging that all people work very very hard for that doctoral degree, not just physicians.

Pharmacists wore long coats historically because it provided them and their clothes the best protection against whatever medicine they were trying to compound. Now that pharmacists are moving onto clinical roles on the wards, many of us are ditching the cumbersome white coat for comfortable business attire.

@ Everyone: Dentists are often addressed as Dr. So and so, but are obviously not medical practitioners. Given this debate on who should be addressed by the term "Dr", where do people stand with regards to dentists? Is there any potential for confusion, given that dental practitioners can also be found in the hospital environment?

I spent a few years teaching clinicals for a local nursing program. One day a student asked, "all the other instructors wear lab coats, why dont you wear a lab coat?"

I replied, "cause I don't work in a lab".

People who wear them to keep their clothes protected, I can understand. I am way too hot natured to wear a coat while working in Florida. I also think it looks odd to wear with scrubs. Plus when they get all dirty with stains and ring around the collar it is just disgusting!

I think this whole debate can be summed up in what Michelle said (I'm paraphrasing) above: For the DNPs, dentists, lawyers, et al., "doctor" is an *honorific*. For the physicians and surgeons, it a *job title*. Think about it.

Especially since the job description of a physician involves, as you mention, being ultimately responsible for the patient and the outcome, the term "doctor" implies all of the above. In addition, as a family physician in urgent care who works with many different types of providers, there is an assumption that physicians have a certain level of training and expertise. Some other types of providers have this, but the truth is that not all do. This is just a fact, that sometimes there is less required training, which can at times lead to a less... involved... medical diagnosis. Yes, some nurse practictioners or P.A.'s have as many years of training, but many do not. I have seen this many times in my 14 years of practice. This is why non-physicians are supposed to have a physician sign off on their work. It's just the way it is. But the funny thing is, I'd almost recommend my own daughters be a P.A. rather than an M.D., just because there is tremendous stress that goes along with this responsibility that we as physicians carry. If a person makes a choice to get a doctorate in nursing, wonderful- but be proud to be a nurse. I think patients are also very aware of all of this, and would make many wrong assumptions if everyone introduced themselves as "doctor".

Optometrist and ophthalmologist is on the forefront of this title confusion. Ophthalmologist has a lot to lose other than title. In many states, optometrists are allowed to treat and prescribe medication even though they never went to medical school. They can see patients without a referral from the Primary care Practioner. In some states they are even allowed to do lasers. They claimed that they have six years of concentrated eye training and even though ophthalmologist went through 12 or more years (if you do a fellowship like Joe), they did not spent as much time on the organ called the EYE. Why are they gaining so much power? The answer is, they have more representation in the Congress. Ophthalmologists, wake up. We have have getting cuts in reimbursements over the years. When I first got out thirty years ago, a cataract surgery was paid at $3000.(medicare and medicaid combined), Now the reimbursement is around five hundred.

Just today a nurse practitioner called, introduced herself as the "attending nephrologist", and proceeded to demand that a repeat study --which served no purpose except exposing the patient to unnecessary radiation --be performed emergently. I know it's one thing to ask to be recognized for the doctorate-level work you put in, and another to lie outright in the name of expediency, but it nonetheless comes down to this--titles have power, and people asking for them know this.

I appreciate your position on this matter, especially since you practice in the hospital where my oncologists, nephrologist and cardiologist are likely to refer me too. And god forbid that I ever end up in your operating room, I promise not to introduce myself.

I am a Masters NP in emergency medicine, where I can assure all I have my own liability insurance and can expect that both I and my "collaborating physician" would be involved in a suit should there be one. Yes, they sign my charts and this suggests that they are involved directly in a patient's care. Their signing my charts is in fact a requirement of our employer and has more to do with billing than collaboration; I am fully licensed to practice and bill independently, but FYI, my reimbursement is lower for the “same” care (face it, I can take care of a sore throat or suture a simple wound as well as my physician colleagues, but would not attempt to perform or bill for a chest tube insertion). Most often are not directly involved in the care of the patients that I see, but in the interest of excellence in patient care (and a cautious, CYA attitude) I do often ask them to see a patient and add their knowledge to my assessment; in those cases they will most often write their own note. They are all trained, board certified, and experienced in ER care, whereas I have 5 years of OJT after 3 in primary care. That said, I am the go to person for diabetes care for many of them, because I have an expertise in that area of medicine; we are a TEAM.

One thing that is often overlooked in NP training is that we have a lot of experience when we enter NP education. Although there are now contiguous degree programs (student to RN to NP in 4-5 years, which interestingly most NP's who came up the traditional way don't agree with *smile*), most schools have a minimum practice requirement of 2 years as an RN before enrollment. In the program that I attended the average number of years’ experience in my group was 13; I personally practiced as an RN for 16 years, 13 in a combined ICU-CCU nurse in a community hospital (on the night shift-we were the cowboys, LOL) before going back to school. So I think there should be a nod to the fact that most of us are not starting from scratch when it comes to patient assessment, care, and clinical knowledge. Most of us do have a little over the first year medical students. By the way, those fast-track RN, BSN to NP degrees are one "solution" to the primary care MD practitioner shortage; at least the nursing profession is offering one. When medical education becomes more affordable and if it continues to take the direction that is has in the last few years with more emphasis on whole patient care and disease prevention rather than disease repair (this is a VERY short version of another whole debate) then maybe more individuals will be drawn to medical, rather than nursing school education. Personally I chose nursing for what I perceived as a more holistic approach toward patient's care when I entered nursing school 32 years ago. If fact, since I admire the advanced knowledge of my ER colleagues in our environment I'd love to have the option of a residency program that was affordable, worked around my current schedule, and ended in a DNP degree. Unfortunately as my nursing colleagues have pointed out, this is not the direction the DNP programs have taken and I am personally thankful that I will not be forced to obtain this degree. I am too old to explain my (theoretical) doctorate to anyone, and already get fatigued explaining to patients that yes, I am a nurse, AND I am also trained and licensed to assess their symptoms, order tests, diagnose their illness and prescribe medications. I also tell them that I'll be arranging their follow-up and have talked to their PCP, or that I have talked to specialist XYZ about their care, or that my ER physician colleague and I have consulted about their diagnosis and that he or she will be examined by that physician if I have asked for that consult. That is how we work as a team.

For those who are interested in the policies, the ENA and the AANP both have position statements and scopes of practice for NPs in the ER setting and here are some references:http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Advanced_Practice_in_Emergency_Nursing_-_ENA_White_Paper.pdf

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